MEDICARE: KINGDOM SOURCE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor
3	101YP1600X	Pastoral Counselor
4	101YP2500X	Professional Counselor
5	104100000X	Social Worker
6	101Y00000X	Counselor

General Provider Information

NPI Number	:	1154698892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGDOM SOURCE, LLC

Provider Business Mailing Address
First Line	:	3226 GRAND POINT HWY
Second Line	:
City	:	BREAUX BRIDGE
State	:	LA
Zip	:	70517-6221
Country	:	US
Telephone Number	:	337-456-6166
Fax Number	:	337-456-4830

Provider Business Practice Location Address
First Line	:	2506 JOHNSTON ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70503-3238
Country	:	US
Telephone Number	:	337-456-6166
Fax Number	:	337-456-4830

Authorized Official
Title or Position	:	DIRECTOR/ OWNER
Name	:	WINFORD LOUIS AMOS
Credential	:	LPC, LAC, CCS
Telephone Number	:	337-456-6166

Provider Enumeration Date	:	11/23/2011
Last Update Date	:	11/26/2019

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Directions to “KINGDOM SOURCE, LLC ” Practice Location

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